One mechanism for ensuring that health insurance provides value to consumers for the premiums that they pay, or that others pay on their behalf, is to require insurers to meet a minimum “medical loss ratio” or MLR standard. The MLR is the share of premium revenues that an insurer or…

This policy brief examines how states in every region have responded to five key opportunities available under the health reform law to help them prepare for the significant expansion of Medicaid in 2014. The options covered in the brief include incentives for states to get an early start on the…

The nearly nine million dual eligibles who receive both Medicare and Medicaid benefits are a high cost, high need population, accounting for a disproportionate share of expenditures relative to their enrollment in both programs. In April 2011, the Centers for Medicare and Medicaid Services (CMS) announced the award of design…

As care delivery and financing models in Medicaid have multiplied, so has the terminology used to refer to them. This glossary seeks to clarify and define the terms that are widely used to describe the diverse approaches that states are taking to reform the way they organize and pay for…

As state and federal policymakers move to develop and test integrated care models for people dually eligible for Medicare and Medicaid, two new Kaiser Family Foundation articles in the June 2012 issue of Health Affairs highlight the diverse needs and challenges facing these 9 million beneficiaries, describe their current care…

This paper provides an overview of the joint efforts of states and the Centers for Medicare and Medicaid Services (CMS) to develop more integrated ways of paying for and delivering health care to the 9 million people who are eligible for both the Medicare and Medicaid programs. Dual eligible beneficiaries…

The Centers for Medicare and Medicaid Services (CMS) has proposed two models to align Medicare and Medicaid benefits and financing for dual eligible beneficiaries, one capitated model and one managed fee-for-service model. In the spring of 2012, 26 states submitted proposals to CMS seeking to test one or both of…

This fact sheet examines the similarities and differences between the five-year demonstrations in Massachusetts and Washington state to integrate care and align financing for people dually eligible for Medicare and Medicaid. The states finalized memoranda of understanding (MOUs) with the Centers for Medicare and Medicaid Services in fall 2012, and…

Way back in the eighties when I was Human Services Commissioner in New Jersey, I established something called the Garden State Health Plan (GSHP). It was the first — and I think the only — federally qualified state-run HMO for Medicaid beneficiaries. One goal of the GSHP was to reallocate…

This background brief provides a comprehensive look at the appeals process for the Medicaid program, which differs significantly from those available through the Medicare program and private health insurance. The Medicaid appeals process provides redress for individual applicants and beneficiaries seeking eligibility for the program or coverage of prescribed services,…